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Three Part Question

In [children <2years] with [proven UTI ]what is the [incidence of significant underlying genito-urinary abnormality]?

Clinical Scenario

A 12 month old baby presents to the Emergency department and you suspect UTI. The hospital policy is to refer to the infant to paediatrics. You wonder why this is the case and the paediatrician explains that it is because of the need to investigate this young age group due to the high incidence of GU abnormalities in children <2years. You wonder what the incidence oF GU abnormality is in children <2years

Search Strategy

Medline, EMBASE and CINAHL via Ovid
Medline: [BestBETs paediatric filter] AND [urinary tract infection.mp./ or exp urinary tract infections/ OR exp bladder, neurogenic/OR urogenital abnormalities.mp./or exp urogenital abnormalities]
Limit humans and english language and abstracts and "reviews (optimized)"
EMBASE: same search as above but Limit to humans and abstracts and english language and infant or preschool child <1 to 6 years>
CINAHL: Same search as above but Limit to abstarcts and english

Search Outcome

Medline 103 papers
EMBASE 476 papers
CINAHL 16 papers
One systematic literature review and 2 prevalence studies were relevant to this BET

Relevant Paper(s)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
E Ring, G Zobel 1988 Austria	140 patients aged between 4 days-12 months, admitted to the paediatric department with their first UTI, between January 1883 and December 1986	Prevalence Study	Incidence of urinary tract malformations	42% (no significant differences in age/sex amongf infants with/without malformations)	Small sample size
				61% had malformations before 3months of age
			incidence of VUR and Obstructive uropthay	VUR 25%, Obstructive uropathy 12%
Cleper R. Krause I. Eisenstein B. Davidovits M 2004 Israel	Files of 64 patients admitted to the paediatric nephrology clinic withe the diagnosis of either neonatal sepsis work-up or neonatal UTI, between January 1997-May 1999	Prevalence Study	Incidence of VUR	20.3% (20% males, 22% females)	Not all urine sample obtained by the same method Small sample size Retrospective Many more makles than females
			Age at diagnosis of UTI	0-7 days 50%, 8-14 days 27% 15-21 days 13%, 22-28 days 0%
Sargent MA Sep 2000 Canada	250 articles from the literature, from a personal collection, electronic literature search, and from references of primary articles, including newborns-18years of age, and publications up to early 1999	Systematic literature review	Incidence of VUR in children with UTI	31.1%	Limitations of the review were identified by the author himself: Less than one third of the articles which were included in the review actually met the inclusion criteria, and there were quite a few papers that wer3 biased in their outcomes which were included. Heterogeniety among age groups among the studies included. Results from different imaging techniques used to diagnose malformations such as UTI with different sensitivities. Heterogeniety of age, sex, grade/type of reflux, history of UTI
			Incidence of VUR in normal children	9.0%
			Incidence of VUR in children <1 year	31.0%
			Incidence of VUR in male UTI	30.0%
			Incidence of VUR in female UTI	33.1%
Jacobson SH. Hansson S. Jakobsson B Nov 1999 Sweden	9 papers including children between 0-18 years of age with VUR and symptomatic UTI	Systematic literature review	Incidence of VUR in children with symptomatic UTI	32%	No methods section with details of search strategies, inclusion criterias etc Heterogenity of age and sex of patients included in various studies Small numbers of papers reviewed
			Incidence of VUR in children with a prenatal diagnosis of urinary tract abnormality	24%

Comment(s)

There is no study that has investigated the incidence of genito-urinary abnormality in children <2years old with proven UTI. The review done by MA Sargent looked into the prevalence of of VUR in children with UTI or other abnormalities, and concluded that the incidence of VUR in children presenting with UTI was equal in children <1year, <5 years and >5years (30.3-31.0%). The other review looking at the incidence of VUR also concluded a similar prevalence of between 30-35%. The only paper identified whuich looked at malformations of the urinary tract in general (and did not just focus on VUR), found that malformations were present in 42% of infants, with 61% having a UTI before 3 months of age, however, this study was very small (140 infants in involved), therefore much more research is needed.

Clinical Bottom Line

No evidence has been found to answer the 3-part question in identifying the incidence of genito-urinary abnormalitiy in children <2 years with proven UTI.

References

1. E Ring, G Zobel Urinary infection and malformations of urinary tract in infancy Archives of Disease in Childhood 63(7)(pp 818-820), 1988
2. Cleper R. Krause I. Eisenstein B. Davidovits M Prevalence of vesicoureteral reflux in neonatal urinary tract infection Clinical Pediatrics 43(7)(pp 619-625), 2004
3. Sargent MA What is the normal prevalence of vesicoureteral reflux? Pediatric Radiology 30(9):587-93, 2000 Sep
4. Jacobson SH. Hansson S. Jakobsson B Vesico-ureteric reflux and other risk factors for renal damage: identification of high- and low-risk children Acta Paediatrica Supplement 88(431):31-9, 1999 Nov